G0463 HCPCS code: Coding Guidelines for coders

Basics about CPT or HCPCS code G0463

In 2014, CMS proposed  to collapse the five levels of evaluation and management (E/M) CPT codes in OPPS (Outpatient Prospective Payment System) and replace them with three new HCPCS G-codes, including one APC for all clinic visits, one for all Type A ED visits, and one for all Type B ED visits. A new HCPCS code G0463, was added to replace the clinic visit code for new and establish patient for Medicare.

Effective January 1, 2014, CMS will provide payment for all qualifying extended assessment and management encounters through newly created composite APC 8009 (Extended Assessment and Management (EAM) Composite). A clinic visit (G0463), a Level 4 (99284) or Level 5 Type A ED visit (99285), or Level 5 Type B ED visit (G0384) furnished by a hospital in conjunction with observation services of eight or more hours will qualify for payment through APC 8009.

G0463 – Hospital outpatient clinic visit for assessment and management of a patient

Effective Jan. 1, 2014, hospitals were required to report outpatient clinic visits furnished to Medicare patients using a single, new HCPCS Level II code, G0463.

  • The single new HCPCS clinic visit code G-code, G0463, a Level 4 or 5 Type A ED visit, or a Level 5 Type B ED visit must be present along with 8 or more hours of observation time
  • The HCPCS code for a direct admission to observation and the CPT codes for critical care remain in place
  • No procedure with status indicator T (significant procedure, multiple reduction applies) can be reported on the same claim

One charge represents the facility or hospital charge and one charge represents the professional or physician fee. The provided-based charge code (G0463) was created for hospital use only, representing any clinic visit under the OPPS, therefore eliminating the need to identify whether the patient is new or established. Secondly, this code does not require an organization to use any specific criteria to determine a level of service. HCPCS Code G0463 is used for all FACILITY evaluation and management visits, regardless of the intensity of service provided.

While this code simplifies some aspects of submitting a hospital outpatient claim for a facility evaluation and management service, it does not eliminate the need for detailed clinical documentation. Clinical support staff is still required to document the services and education provided to the patient during their visit. Therefore, there must be clinical documentation by the clinical support staff found in the chart to substantiate billing G0463 by the facility representing overhead expenses. Submission of a physician history and physical or a physician progress note as part of an appeal does not provide evidence to support facility cost and will be denied.

Clinic Visit New patient (in 2013) – 99201,99202, 99203, 99204       

Clinic Visit Establish patient (in 2013) – 99211,99212, 99213, 99214

Clinic Visit New & Establish patient (in 2014) – G0463

There is no difference between new and established patient visits reported using G0463. 

The HCPCS code was created by Medicare to be reported by those hospitals reimbursed by APCs, Medicare OPPS. However, not all hospitals are reimbursed under this payment system and there lies the confusion. 

For hospital outpatient/clinic visits for services before 1st January, 2014 codes 99201-99205 and 99211-99215 translated to five distinct ambulatory payment classifications (APCs) for outpatient reimbursement.

For 2019, the proposed unadjusted Medicare payment rate under the OPPS for a clinic visit would be approximately $116. The proposed unadjusted Medicare Physician Fee Schedule (MPFS) equivalent rate that clinics would instead be paid is approximately $46.

For CY 2019, CMS proposes that when reporting HCPCS code G0463 (hospital outpatient clinic visit for assessment and management of a patient), providers that append modifier -PO (excepted service provided at an off-campus, outpatient PBD of a hospital) will be paid at the same rate as those that append modifier -PN (nonexcepted service provided at an off-campus, outpatient PBD of a hospital).

Reimbursement Guidelines for HCPCS code G0463

25 modifier can be used with HCPCS code G0463. Code G0463 is an E&M service in the facility so the 25 modifier is appropriate.

G0463 must be reported with either modifier PN or modifier PO when required by CMS.

HCPCS modifier PO is to be reported with every HCPCS code for all outpatient hospital items and services furnished in an excepted off-campus provider-based department of a hospital. This applies to G0463 and all other billed procedure codes.

HCPCS modifier PN is to be reported with every HCPCS code for all outpatient hospital items and services furnished in a non-excepted off-campus provider-based department of a hospital. This applies to G0463 and all other billed procedure codes, including those for which payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services.

NCCI edits for code G0463

Below are the NCCI edits for code G0463. Do check the edits between below CPT or HCPCS codes and assign modifiers properly.

Major Code/Column 1Minor Code/Column 2Effective DateDeletion DateModifier/Policy Indicator
G04633659110/1/2015*0-Not allowed
G04633659210/1/2015*0-Not allowed
G0463437527/1/2014*1-Allowed
G0463805007/1/201412/31/20210-Not allowed
G0463805027/1/201412/31/20210-Not allowed
G0463805031/1/2022*0-Not allowed
G0463805041/1/2022*0-Not allowed
G0463805051/1/2022*0-Not allowed
G0463805061/1/2022*0-Not allowed
G0463908637/1/2014*0-Not allowed
G0463909407/1/2014*0-Not allowed
G0463920027/1/2014*0-Not allowed
G0463920047/1/2014*0-Not allowed
G0463920127/1/2014*0-Not allowed
G0463920147/1/2014*0-Not allowed
G0463922277/1/2014*1-Allowed
G0463922287/1/2014*1-Allowed
G0463925317/1/2014*0-Not allowed
G0463925327/1/2014*0-Not allowed
G0463935617/1/201412/31/20211-Allowed
G0463935627/1/201412/31/20211-Allowed
G0463935981/1/2022*1-Allowed
G0463937921/1/2018*1-Allowed
G0463937931/1/2018*1-Allowed
G0463940027/1/2014*0-Not allowed
G0463940037/1/2014*0-Not allowed
G0463940047/1/2014*0-Not allowed
G0463946601/1/2016*0-Not allowed
G0463946621/1/2016*0-Not allowed
G0463958317/1/201412/31/20190-Not allowed
G0463958327/1/201412/31/20190-Not allowed
G0463958337/1/201412/31/20190-Not allowed
G0463958347/1/201412/31/20190-Not allowed
G0463958517/1/2014*0-Not allowed
G0463958527/1/2014*0-Not allowed
G0463960207/1/2014*1-Allowed
G0463961017/1/201412/31/20181-Allowed
G0463961027/1/201412/31/20181-Allowed
G0463961037/1/201412/31/20181-Allowed
G0463961057/1/2014*1-Allowed
G04639611610/1/2020*1-Allowed
G0463961167/1/201412/31/20191-Allowed
G0463961187/1/201412/31/20181-Allowed
G0463961197/1/201412/31/20181-Allowed
G0463961207/1/201412/31/20181-Allowed
G0463961257/1/2014*1-Allowed
G0463961271/1/2015*0-Not allowed
G04639613010/1/2020*1-Allowed
G0463961301/1/201912/31/20191-Allowed
G0463961321/1/201912/31/20191-Allowed
G04639613210/1/2020*1-Allowed
G0463961361/1/201912/31/20191-Allowed
G04639613610/1/2020*1-Allowed
G0463961381/1/201912/31/20191-Allowed
G04639613810/1/2020*1-Allowed
G0463961461/1/2019*1-Allowed
G0463961507/1/201412/31/20190-Not allowed
G0463961517/1/201412/31/20190-Not allowed
G0463961527/1/201412/31/20190-Not allowed
G0463961537/1/201412/31/20190-Not allowed
G0463961547/1/201412/31/20190-Not allowed
G0463961561/1/20201/1/20209-Not applicable
G04639615610/1/2020*0-Not allowed
G0463961581/1/20201/1/20209-Not applicable
G04639615810/1/2020*0-Not allowed
G0463961591/1/20201/1/20209-Not applicable
G04639615910/1/2020*0-Not allowed
G04639616410/1/2020*0-Not allowed
G0463961641/1/20201/1/20209-Not applicable
G0463961651/1/20201/1/20209-Not applicable
G04639616510/1/2020*0-Not allowed
G0463961671/1/20201/1/20209-Not applicable
G04639616710/1/2020*0-Not allowed
G0463961681/1/20201/1/20209-Not applicable
G04639616810/1/2020*0-Not allowed
G0463965237/1/2014*0-Not allowed
G0463971691/1/2020*0-Not allowed
G0463971701/1/2020*0-Not allowed
G0463971711/1/2020*0-Not allowed
G0463971721/1/2020*0-Not allowed
G04639780210/1/2020*0-Not allowed
G0463978027/1/201412/31/20190-Not allowed
G04639780310/1/2020*0-Not allowed
G0463978037/1/201412/31/20190-Not allowed
G04639780410/1/2020*0-Not allowed
G0463978047/1/201412/31/20190-Not allowed
G0463991727/1/2014*0-Not allowed
G04639920110/1/202012/31/20201-Allowed
G0463992017/1/201412/31/20191-Allowed
G04639920210/1/2020*1-Allowed
G0463992027/1/201412/31/20191-Allowed
G0463992037/1/201412/31/20191-Allowed
G04639920310/1/2020*1-Allowed
G0463992047/1/201412/31/20191-Allowed
G04639920410/1/2020*1-Allowed
G0463992057/1/201412/31/20191-Allowed
G04639920510/1/2020*1-Allowed
G0463992117/1/201412/31/20191-Allowed
G04639921110/1/2020*1-Allowed
G0463992127/1/201412/31/20191-Allowed
G04639921210/1/2020*1-Allowed
G0463992137/1/201412/31/20191-Allowed
G04639921310/1/2020*1-Allowed
G0463992147/1/201412/31/20191-Allowed
G04639921410/1/2020*1-Allowed
G0463992157/1/201412/31/20191-Allowed
G04639921510/1/2020*1-Allowed
G0463994087/1/2014*0-Not allowed
G0463994097/1/2014*0-Not allowed
G0463994467/1/2014*0-Not allowed
G0463994477/1/2014*0-Not allowed
G0463994487/1/2014*0-Not allowed
G0463994497/1/2014*0-Not allowed
G0463994511/1/2019*0-Not allowed
G0463994521/1/2019*0-Not allowed
G0463994637/1/2014*0-Not allowed
G04639948310/1/2020*1-Allowed
G0463994831/1/201812/31/20191-Allowed
G0463994971/1/20151/1/20159-Not applicable
G0463996057/1/2014*1-Allowed
G0463996067/1/2014*1-Allowed
G0463G01027/1/2014*0-Not allowed
G0463G01177/1/2014*0-Not allowed
G0463G01187/1/2014*0-Not allowed
G0463G02457/1/2014*0-Not allowed
G0463G02467/1/2014*0-Not allowed
G0463G02487/1/2014*1-Allowed
G0463G02507/1/2014*1-Allowed
G0463G02707/1/201412/31/20190-Not allowed
G0463G027010/1/2020*0-Not allowed
G0463G02717/1/2014*0-Not allowed
G0463G039610/1/2020*1-Allowed
G0463G03967/1/201412/31/20191-Allowed
G0463G03977/1/201412/31/20191-Allowed
G0463G039710/1/2020*1-Allowed
G0463G044210/1/2020*1-Allowed
G0463G04427/1/201412/31/20191-Allowed
G0463G044310/1/2020*1-Allowed
G0463G04437/1/201412/31/20191-Allowed
G0463G04447/1/201412/31/20191-Allowed
G0463G044410/1/2020*1-Allowed
G0463G044510/1/2020*1-Allowed
G0463G04457/1/201412/31/20191-Allowed
G0463G04467/1/201412/31/20191-Allowed
G0463G044610/1/2020*1-Allowed
G0463G04477/1/201412/31/20191-Allowed
G0463G044710/1/2020*1-Allowed
G0463G04597/1/201412/31/20190-Not allowed
G0463G045910/1/2020*0-Not allowed
G0463G04737/1/2015*1-Allowed
G0463G05057/1/201712/31/20171-Allowed
G0463G20117/1/2019*1-Allowed
G0463M00647/1/201412/31/20140-Not allowed

References:

https://www.hcpro.com/HIM-299741-8160/CMS-replaces-clinic-EM-visit-levels-with-single-Gcode.html

https://www.hipaaspace.com/medical_billing/coding/healthcare.common.procedure.coding.system/g0463

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